New Client Intake Formalign2move@gmail.com Name * First Name Last Name Email * Date * MM DD YYYY Mobile * Emergency Contact (In case of emergency, please contact) * First Name Last Name Emergency Contact Mobile * HEALTH QUESTIONNAIRE FOR CLIENTS : Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? * Yes No Do you feel pain in your chest when you perform physical activity? * Yes No Do you lose your balance because of dizziness or do you ever lose consciousness? * Yes No Do you have a bone or joint problem that could be made worse by a change in your physical activity? * Yes No Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? * Yes No Do you know of any other reason why you should not engage in physical activity? * Yes No If you have answered “Yes” to one or more of the above questions, consult your physician before engaging in physical activity. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition. What is your current occupation? * Does your current daily routine require prolonged sitting? * Does your daily routine involve repetitive movements? If yes, please describe: * Describe any current or previous episodes of pain or injury: * Thank you! Please read and sign the Waiver below. Looking forward to introducing you to Foundation Training!Jacqui
